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CQC report explained · a residential care home

What the CQC found at St Brendan's Care Home

Goodpublished 18 March 2022, 4 years ago

Rated Good: inspectors found the home performing well and meeting their expectations.

The five questions inspectors ask
Safe?
Good
People said they felt safe. Inspectors found personalised risk assessments, appropriate recruitment checks, safe medicines arrangements and suitable infection control.
Effective?
Good
This question was not inspected during this visit. Its previous rating was used when calculating the overall rating.
Caring?
Good
This question was not inspected during this visit. Its previous rating was used when calculating the overall rating.
Responsive?
Outstanding
This question was not inspected during this visit. Its previous rating was used when calculating the overall rating.
Well-led?
Good
Inspectors found approachable management, good communication, staff involvement and quality checks that identified and acted on shortfalls.
The latest report, explained

What inspectors found, March 2022

Rated Good; a focused inspection found safe care systems and good leadership, although the manager was not yet registered.

This was an unannounced, focused inspection after concerns about staffing levels. One inspector and an Expert by Experience spoke with 12 people and seven staff. They also reviewed care, medicines, recruitment and management records.

The home was rated Good for Safe. People said they felt safe. Inspectors found personalised risk assessments, suitable staff checks, safe medicines records and effective infection control. They found no evidence that the staffing concern had put people at risk.

The home was rated Good for Well-led. Inspectors found an open culture, approachable managers and quality checks that helped identify and act on issues. The overall rating stayed Good, but Caring, Effective and Responsive were not inspected during this visit. Their previous ratings were used for the overall rating.

What inspectors praised
  • People felt safe

    People told inspectors they felt safe, and staff understood how to recognise and report abuse.

    “People felt safe in the home and liked the staff who supported them.” from the report
  • Personalised risk planning

    Risk assessments gave clear, individual information about risks and how staff should reduce them.

    “Risk assessments were consistent and clear and the guidance that staff should take to mitigate risks was accurately recorded and had improved since the last inspection.” from the report
  • Safe medicines practice

    Inspectors found no gaps in the medicines records they checked. Medicines were stored securely and given at the correct time during the observed round.

    “We reviewed people's MAR charts and no recording gaps were seen.” from the report
  • Open management culture

    Staff said communication, teamwork and morale had improved. People, relatives and staff had opportunities to give feedback, and the home acted on comments.

    “Meetings for residents, relatives and staff had taken place and improvements to the service had been made based on the comments made.” from the report
  • Learning from incidents

    The management team reviewed accidents and identified falls as a pattern. It took further action, including better communication with hospitals before admission.

    “There was evidence that the management team investigated incidents and accidents appropriately and identified themes and trends.” from the report
What inspectors were concerned about
  • Manager registration was incomplete

    minor

    There was no manager registered with CQC when inspectors visited. The manager had started the application process.

    “Although there was no registered manager of the service, the manager had submitted an application to register with CQC.” from the report
Questions to ask them, based on this report
  1. 01What are the current staffing levels on each shift, and how often are agency staff used?
  2. 02Has the manager's application to register with CQC been completed?
  3. 03What changes were made after residents' and relatives' feedback, and how do you check that they worked?
  4. 04What actions are currently being taken to reduce falls and improve communication with hospitals before admission?

This was a focused inspection of Safe and Well-led only; Caring, Effective and Responsive were not inspected and their previous ratings were used for the overall rating. This explanation was written from the published report of 18 March 2022 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.

An earlier report, explained

What inspectors found, February 2021

Inspected but not rated; inspectors found strong infection control and safe arrangements for visitors, testing and admissions.

This was an unannounced, targeted inspection on 9 December 2020. It focused only on infection prevention and control during the coronavirus pandemic.

Inspectors were assured that the home was managing visitors, distancing, personal protective equipment, testing, cleaning and new admissions safely. The home had systems to isolate people when needed and to manage infection outbreaks.

The home was inspected but not rated. This means the inspection did not give an overall quality rating or a full rating across all five areas of care.

What inspectors praised
  • Safer family visits

    The home used temperature and symptom checks and provided a separate visiting room with outside access and screens. It also supported video and telephone calls when visits were not possible.

    “Family visits had been facilitated through a separate room with its own access from outside using screens.” from the report
  • Protective equipment and training

    Inspectors found that personal protective equipment guidance was being followed. Staff received frequent infection control and protective equipment training.

    “Frequent training on IPC and PPE was provided by the provider, via a roadshow with the infection control lead, and from the clinical commissioning group (CCG).” from the report
  • Testing and infection monitoring

    The provider carried out regular testing in line with government guidance, including testing agency staff. Testing records were described as well recorded.

    “The provider used regular testing in line with government guidance which was well recorded.” from the report
  • Safe admissions and cleaning

    New admissions were tested and kept in a separate zoned area for 14 days. Night staff carried out deep cleaning with approved products.

    “The provider had a thorough policy for admissions including COVID-19 testing and a zoned area for 14 days to isolate people on admission from other residents in the home.” from the report
What inspectors were concerned about

Inspectors raised no specific concerns in this report.

Questions to ask them, based on this report
  1. 01How are family visits arranged now, and what checks are made before visitors enter?
  2. 02How often are residents, staff and agency staff tested now?
  3. 03How are new residents isolated and supported during their first 14 days?
  4. 04What infection prevention and control training do staff receive now?
  5. 05How are cleaning arrangements checked, including overnight deep cleaning?

This was an unannounced targeted inspection of infection prevention and control during the coronavirus pandemic; it did not provide a full rating of the home or assess all five areas of care. This explanation was written from the published report of 11 February 2021 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.

The story over the years

Every inspection of St Brendan's Care Home

2 rated inspections over 3 years: the service has held its Good rating throughout.

  1. March 2022Goodcurrent rating
    Safe: GoodEffective: GoodCaring: GoodResponsive: OutstandingWell-led: Good

    Read what inspectors found at St Brendan's Care Home →

  2. February 2021Inspected but not rated
    Safe: Inspected but not rated

    Read what inspectors found at St Brendan's Care Home →

  3. October 2018Good
    Safe: GoodWell-led: Good

    Read this report on cqc.org.uk

  4. September 2017

    Registered with the Care Quality Commission on 20 September 2017.

Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.

Next steps

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